WHAT THE EXPERTS SAY
Thrombus has been shown to increase risks such as abrupt vessel closure, death, MI, and emergency bypass surgery. Thrombus removal can help improve outcomes by allowing for better visualization of vessel morphology and potentially reducing distal embolization.1
In the TOTAL trial, routine manual aspiration (MA) thrombectomy compared to PCI alone did not reduce death from cardiovascular causes, recurrent MI, cardiogenic shock, or class IV heart failure within 180 days.2 The results from the trial are consistent with the standard thrombus algorithm in that manual aspiration is not appropriate for all levels of thrombus burden and should be used selectively in small thrombus burden.3
Routine manual thrombectomy was associated with a number of procedural benefits as compared to PCI only:2
Outcomes |
PCI + MA (n = 5,033) |
PCI Alone (n = 5,030) |
P value |
|---|---|---|---|
Incomplete ST segment resolution (<70%) |
27.0% |
30.2% |
P < .001
|
Distal embolization |
1.6% |
3.0% |
P < .001 |
Direct stenting |
38.3% |
21.3% |
P < .001 |
Importantly, some TOTAL patients assigned to PCI alone required bailout thrombectomy, which study investigators note highlights a continued need for clinical judgment, especially in deteriorating patients in which the operator’s current strategies are not working.4
The TOTAL trial, in which 75% of the patients enrolled presented with large thrombus burden, highlights the need for a selective rather than routine approach to thrombectomy. Per the thrombus algorithm, small thrombus is treated with manual aspiration while large thrombus (grade 4 and 5) may be effectively treated with ANGIOJET™ mechanical thrombectomy.3